While acknowledging that incorrect and incomplete communication represent a leading cause of preventable adverse outcomes, analyzing the impact of this problem outside the hospital is admittedly very challenging. There are a number of plausible reasons for the minimal focus on this issue:
- The hospital might be unaware the patient had a complication or died
- If the patient had a serious problem, he or she might have gone to another hospital for treatment
- If the patient returns to the same hospital, there may be no awareness that a clinical action was responsible for the patient’s need to seek further treatment
- Even if hospitals were interested in pursuing this opportunity, many are struggling with reduced reimbursement for their services, and they may believe there are insufficient resources to quantify and address the need
Despite the data collection and other inherent challenges, existing quality assurance and risk management programs should be expanded to identify and reduce adverse outcomes following a patient’s ER discharge. Convenient rationalizations for not taking action will eventually be trumped by irrefutable evidence that systems-based efforts reduce complications and deaths.
Whether being discharged from the ER or from an inpatient bed, a recent report indicated one in five patients are discharged with unstable vital signs—a likely cause of deaths and readmissions (Nguyen et al., 2016). The problem is exacerbated by continuing major deficits in transitional care. In the May 2, 2016 issue of Kaiser Health News, Alicia Arbaje, an assistant professor at the Johns Hopkins School of Medicine, is quoted as saying, “Poor transitional care is a huge, huge issue for everybody, but especially for older people with complex needs. The most risky transition is from hospital to home with the additional need for home care services, and that’s the one we know the least about.” The same article noted: “Nearly every step of the process features potential pitfalls. At hospitals, a minority of patients say they understood instructions about post-discharge self-care” (Rau, 2016).
But the problem is not just related to home discharges. According to a study published in August 2016 by faculty at the University of Colorado School of Medicine, over 22% of patients discharged to postacute care (PAC) facilities following hospitalization were readmitted at least once within 30 days. Nearly half of the readmissions occurred within two weeks of discharge. The authors stated that under current payment systems, “hospitals are incentivized to discharge these patients as early as possible, and in contrast to discharges home, hospitals are not currently penalized for readmissions from PAC facilities. PAC facilities may be substituting for prolonged hospital care in some cases” (Burke, et al., 2016)
A genuine commitment to population health management demands attention to this issue. Over 147 million patients were seen in U.S. ERs in 2015 according to unpublished 2016 data from the AHA Annual Survey Database™, used with permission of the American Hospital Association. The vast majority are discharged to home. The obvious question is: What practical steps should hospitals take to identify and address the prevention of complications and deaths related to patients’ ER treatment after they are discharged?
Recommendations for reducing complications after discharge
The following recommendations should be modified depending on an ER’s existing program for addressing this issue:
- Identify the underlying causes of complications that are manifested post-discharge and develop appropriate countermeasures that reduce their likelihood of occurrence.
- Develop and implement a risk-based prioritization system to identify patients at high risk of harm from post-discharge complications that require intervention, and link the system to specific actions that address the underlying causes of that increased risk.
- Establish processes that clearly define who is responsible for carrying out the various steps related to the identification of patients at risk, implementation of mitigating actions, and quality assurance activities to determine whether intended processes are being employed and whether they are successful.
- Prepare a list of questions to ask patients or surrogates via phone, email, or text within 24 hours of discharge.
- Develop suggested actions to be taken depending on responses to questions (e.g., return to ER, make prompt appointment with primary care physician).
- Designate an individual with responsibility for contacting high- and then medium-risk patients.
- Make follow-up contact with the patient or surrogate within 24 hours of initial contact.
- Establish a database to facilitate review and refinement of processes and outcomes.
- Explore technological tools to improve patient communication post-discharge. For example, SMARTworks® EffectiveResponse is promoted as an electronic survey tool that reduces risk and improves satisfaction for patients discharged from the ER (Salber, 2015).